FY 2014 Inpatient PPS

Proposed Rule Quality

Provisions Webinar

May 23, 2013

AAMC Staff: Scott Wetzel, swetzel@aamc.org Mary Wheatley, mwheatley@aamc.org

Important Info on Proposed Rule

• In Federal Register on May 10 – available at http://www.gpo.gov/fdsys/pkg/FR-2013-05-10/pdf/2013-10234.pdf

• Comments due June 25, 2013

• Slides Posted: www.aamc.org/hospitalpaymentandquality

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Key Proposals

• Hospital Acquired Condition (HAC) Reduction Program

• Starts in 2015, disproportionately affects teaching hospitals

• 1% reduction affects Base DRG, IME, DSH

• Value Based Purchasing (VBP) • Domain weights shift from process to outcome measures

starting in FY2016

• Readmissions • Inclusion of planned readmission algorithm starting in FY 2014

• Add COPD, Total Hip/Knee Arthroplasty in FY 2015

• IQR • Voluntary EHR reporting for some IQR measures – also meets

MU CQM criteria

• New COPD and stroke mortality and readmission measure

• New AMI efficiency measure

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Page Numbers in Federal

Register

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Program Starting Page in

Federal Register

HACS Pg. 27622

VBP Pg. 27606

Readmissions Pg. 27594

IQR Pg. 27677

Hospital Acquired Condition (HAC)

Reduction Program

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• HHS Secretary must establish a HAC payment adjustment (reduction of 1 percent for affected hospitals) for all inpatient hospital payments

• Appears to include IME and DSH

• Applies to a quarter of all hospitals (those with lowest performance)

• “Hospital acquired condition” definition – look to the HAC Nonpayment Program and any other condition determined appropriate by the Secretary.

• This HAC program is in addition to the HAC Non-Payment Program

• Reductions will be applied after adjustments for the VBP and the readmissions programs

• HAC program starts FY 2015

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Section 3008 of ACA

Requirements

HAC Reduction Program Framework

Measures

Domains

Total Score

Total HAC Score

Domain 1

AHRQ Patient Safety

Indicators

AHRQ Composite

Domain 2

CDC NHSN

measures

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OR

Similar to VBP:

However: Different methodology to assign points

Worse performance = more points

Most hospitals receive zero points for each measure

No improvement points

Worst quartile

receives

automatic 1%

reduction

Measures and Domains FY 2015

Domain 1

(6 AHRQ PSI Measures)

• PSI-3: Pressure Ulcer

• PSI-5: Foreign Object left in body

• PSI-6: Iatrogenic pneumothorax

• PSI-10: Postoperative physiologic and metabolic derangement rate

• PSI-12: Postoperative PE/DVT rate

• PSI-15: Accidental puncture

Alternative

Domain 1

(AHRQ Composite)

• PSI-90: Composite measure, which includes:

• PSI-3: Pressure Ulcer

• PSI-6: Iatrogenic pneumothorax

• PSI-7: central venous cathetar-related blood streem infection rate.

• PSI-8: hip fracture rate

• PSI-12: Postoperative PE/DVT rate

• PSI-13: sepsis rate

• PSI-14: wound dehiscence rate

• PSI-15: Accidental puncture

Domain 2

CDC NHSN Measures

• CLABSI

• CAUTI

• 2016

• Surgical Site Infection (Colon Surgery and Abdominal Hysterectomy)

• 2017

• MRSA

• C. Diff

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OR

FFS claims based data

24 month data period

Measures adverse events across

hospitals

Risk adjusted at patient level

Chart abstracted data

Reported Quarterly

Measures adverse events at unit level

Risk adjusted at hospital level and

patient care unit level

Proposed Measure Scoring

• Hospitals only receive points if measure performance is in lowest quartile

o Hospitals in top three quartiles for each measure will receive 0 points

o EXCEPTION: Any incidence of PSI-5 (foreign object left in body) over 2 years = automatic 10 points.

• Hospitals in lowest quartile: measures scored on sliding scale between 1 and 10 points

o Lowest quartile is divided into 10 percentiles for each measure

• Each measure weighted equally in the domain

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Example of Measure Scoring (PSI-3)

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• Performance in worse quartile for PSI-3 ranges from .3300 to .3400

• Hospital A scored .3378, placing them in the 8th percentile range

• Hospital A receives a total of 8 points on this measure

Proposed Domain

Weighting/Scoring

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50%

50%

Domain 1 Domain 2

Exceptions:

Hospitals reporting fewer than 3 measures in Domain 1, no Domain 1 score will be calculated

Hospitals reporting 3-5 measures in Domain 1 will be calculated with completed measures

If SIR cannot be calculated for at least 1 measure in Domain 2, only domain 1 measures will be used

If ICU waiver, then calculate total HAC score only using Domain 1

If you do not have an ICU, but do not receive an ICU waiver = 10 pts for domain 2

CMS Estimates Teaching Hospitals

will be Disproportionately Affected

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• 56% of teaching hospitals estimated to be affected

• Calculation is based on CMS data, which has not been verified

Additional Issues

• 30 day review and correction period

o Claims cannot be corrected or submitted during review and correction period

• Data Collection periods:

o Domain 1: July 2011 – June 2013

o Domain 2: CYs 2012 and 2013

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AAMC Questions for the Group

HAC Reduction Program

• Reactions to the proposed HAC measures

For domain 1, is there a preference for a domain of 6 PSI indicators or the AHRQ composite?

• Are there concerns with the measure scoring methodology and/or the domain weighting?

• Suggestions to remove overlap between measures in HAC reductions program and VBP

– AHRQ PSI-90 Composite

– CDC NHSN measures

• Other concerns?

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Value Based Purchasing (VBP)

Program

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Updates to VBP Program

for FY 2014

• Base DRGs increased from 1% to 1.25% to fund incentive pool

• Approximately $1.1 billion will be available for incentive payments

• This is the first year of outcome measures

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Measures Proposed for Removal

Starting FY 2016

• Primary PCI received within 90 minutes of arrival

• Blood cultures performed in ED prior to Initial Antibiotic

• Heart failure discharge instructions

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Proposed Additional Measures

Starting FY 2016

• Three new measures

• Influenza Immunization

• CAUTI

• SSI (colon and hysterectomy)

• CLABSI readopted for FY 2016 (NQF still reviewing reliability adjustment)

(The full list of proposed/finalized measures in the VBP program can be found on page 27611 )

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Proposed Performance Periods: POC, HCAHPS,

Efficiency, Mortality, and AHRQ measures

FY 2016

Domain Baseline Period Performance Period

Clinical Process of Care January 1, 2012 – December 31, 2012 January 1, 2014 – December 31, 2014

Patient Experience January 1, 2012 – December 31, 2012 January 1, 2014 – December 31, 2014

Efficiency January 1, 2012 – December 31, 2012 January 1, 2014 – December 31, 2014

FY 2017

Outcome

• Mortality

• AHRQ PSI

• October 1, 2010 – June 30, 2012

• October 1, 2010 – June 30, 2012

• October 1, 2013 – June 30, 2015

• October 1, 2013 – June 30, 2015

FY 2018

Outcome

• Mortality

• AHRQ PSI

• October 1, 2009 – June 30, 2012

• July 1, 2010 – June 30, 2012

• October 1, 2013 – June 30, 2016

• July 1, 2014 – June 30, 2016

FY 2019

Outcome

• Mortality

• AHRQ PSI

• July 1, 2009 – June 30, 2012

• July 1, 2010 – June 30, 2012

• July 1, 2014 – June 30, 2017

• July 1, 2015 – June 30, 2017

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Proposed VBP Domains for FY 2016

10%

40% 25%

25%

Proposed Domain Weighting FY 2016

Process

Outcomes

Efficiency

HCAHPS

20%

30% 20%

30%

Finalized Domain Weighting FY 2015

Process

Outcomes

Efficiency

HCAHPS

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FY 2016 Domains

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FY 2016

Domain/Weight Measures

Outcomes

40%

• CAUTI

• CLABSI

• AHRQ Composite

• SSI

• AMI, HF, PN Mortality

Process of Care

(POC)

10%

• 10 POC measures

Patient Experience

25% • HCAHPS

Efficiency

25% • MSPB

Reclassifying 2017 Domain Weights to NQS

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FY 2016 FY 2017

Domain/Weight Measures Domain/Weight Measures

Outcomes

40%

• CAUTI

• CLABSI

• AHRQ Composite

• SSI

• AMI, HF, PN Mortality

Safety

15%

• CAUTI

• CLABSI

• AHRQ Composite

• SSI

Process of Care

(POC)

10%

• 10 POC measures

Clinical Care 35%

• Outcomes (25%)

• Process

(10%)

• AMI, HF, PN

Mortality

• 10 POC measures

Patient Experience

25% • HCAHPS

Patient Experience/

Care Coordination

25%

• HCAHPS

Efficiency

25% • MSPB

Efficiency and Cost

Reduction

25%

• MSPB

Proposed VBP Disaster Waiver

• Similar to IQR disaster waiver program.

• Hospitals that face extraordinary circumstances may apply for a waiver that will effectively exclude them from the VBP program for a fiscal year

• Application must be filed within 30 days of occurrence

• Few hospitals likely to receive waivers

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Readmissions Reduction Program

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Changes to Readmissions

Reduction Program

• Maximum penalty increased to 2%

• Projected $175 million less in payments

• Added planned readmissions logic

• Two new measures to program starting in FY2015

• Applicable time period for FY2014

o July 1, 2009 through June 30, 2012

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Planned Readmissions

• Incorporation of planned readmissions algorithm (Version 2.1)

o Applied to AMI, HF, and PN measure starting FY 2014

• CMS will not count unplanned readmissions that follow a planned readmission within 30 days of the initial index admission.

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New Measures for FY 2015

• ACA stated that CMS had to expand readmissions program starting in FY2015

• COPD (suggested by MedPAC)

• Elective THA/TKA

• CMS indicated other MedPAC-suggested measures (CABG, PCI, and Other Vascular) were not feasible to add

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Inpatient Quality Reporting (IQR)

Program

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Removal/Suspension of Measures

For FY 2016

Continued suspension:

AMI-1, AMI-3, AMI-5, SCIP Inf-6

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Proposed Refinements to Existing

Measures for FYs 2015 and 2016

• Adding planned readmission algorithm for HF, AMI, PN, THA/TKA, and hospital-wide readmissions

• Expansion of CLABSI and CAUTI to select non-ICU locations

• Updates to SCIP Inf-4 to incorporate NQF changes

• Update to MSPB to include Railroad Retirement Board (RRB) beneficiaries

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Proposed Addition of 5 claims

based measures for FY 2016

• 30-day risk standardized COPD readmissions

• 30- day risk standardized COPD mortality

• 30- day risk standardized stroke mortality

• 30- day risk standardized stroke readmission

• AMI payment per episode of care

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Voluntary EHR Submission that

Aligns IQR and Meaningful Use

Proposed data submission requirements:

• Hospitals have the ability to electronically report 16 measures across four measure sets (STK, VTE, ED, and PC)

• Hospitals must electronically report at least one quarter of CY 2014 quality measure data for each measure in the four measure sets

• CMS intends to use the electronically reported data to determine whether the hospital has satisfied the MU reporting requirement.

• Must use MU reporting process for submitting quality measures finalized in stage 2

• Data that is electronically reported will not be publicly displayed for CY 2014.

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Proposed Data Validation Changes

for Chart Abstracted Measures

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New data validation time periods/measure selections proposed:

FY 2015

• Validation period would be October 1, 2012 through June 30, 2013

• 12 process of care measures and 2 HAI measures would be validated

• Validation would be suspended for 9 measures

FY 2016

• Validation period would be July 1, 2013 through June 30, 2014.

Additional Issues

• Data submission requirements for chart abstracted measures

o Still 4.5 months quarterly submission deadline. However, deadline is set at midnight Pacific Time

• Star rating for Hospital Compare

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AAMC Questions for the Group

Readmissions

• Questions/concerns regarding new measures (COPD, THA/TKA)

VBP

• Proposed domain weight changes for the FY 2016 and 2017

Increased outcome, increased efficiency, decreased process

Moving to new domains (i.e. safety and clinical care)

IQR

• Are there specific concerns with electronically reporting the IQR data?

• New mortality, readmissions and AMI episode of care measure

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Thank You!

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